michigan medicine, volume 115, no. 2

www.msms.org

A W A R D - W I N N I N G M A G A Z I N E O F T H E M I C H I G A N S T A T E M E D I C A L S O C I E T Y

ALSO IN THIS ISSUE

• There’s An App for That: The Benefits and Risks of Using Mobile Apps for Health Care

• Vaccinating Against Preventable Disease

• Telemedicine in Michigan: What Physicians Need to Know

March / April 2016 • Volume 115 • No. 2

Rural Practices:Founded in Family

and CommunityMSMS member Jennifer Dehlin, MD, explains the

challenges and opportunities that come along

with practicing in rural Michigan.

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COVER STORY18

Rural Practices: Founded in Family and CommunityBy Kathryn Palczewski

FEATURES26

There’s An App for That:The Benefits and Risks of Using Mobile Apps for Health Care

by Robin Diamond, MSN, JD, RN, Senior Vice President, Patient Safety and Risk Management, The Doctors Company

(Contributed by The Doctors Company)

COLUMNS4

President’s PerspectiveBy Rose M. Ramirez, MD

Encouraging Physician Roots to Grow in Rural Areas of Michigan6

Ask Our LawyerBy Daniel J. Schulte, JD

Greater Publication of State Disciplinary Actions MakesCompliance Conference Settlements More Difficult

8MDHHS Update

By Cristi Bramer, MPH, MCIR Epidemiologist, MDHHS Division of Immunization

Over a Third of Young Children in Michiganare Susceptible to Vaccine Preventable Diseases

10HIT Corner

By Patrick J. Haddad, JD, Kerr, Russell and Weber, PLC, MSMS Legal CounselTelemedicine in Michigan: What Physicians Need to Know

16MSMS Alliance

By Clara Sumeghy, President, MSMS AllianceReport on the Status of MSMS Alliance Works in Progress

DEPARTMENTS24

In Memoriam28

MSMS Foundation Education Course Offerings30

New MSMS Members31

The Marketplace34

WealthCare Advisors

The mission of the Michigan State Medical Society is to promote a health care environment which supports physicians in caring for and enhancing the health of Michigan citizens through science, quality and ethics in the practice of medicine.

Chief Executive OfficerJULIE L. NOVAK

Managing EditorKEVIN MCFATRIDGEEMAIL: [email protected]

Publication OfficeMichigan State Medical SocietyPO Box 950, East Lansing, MI 48826-0950517-337-1351

www.msms.org

All communications on articles, news, exchanges and classified advertising should be sent to the aboveaddress, attn: Kevin McFatridge.

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Postmaster: Address ChangesMichigan MedicineHannah DingwellPO Box 950, East Lansing, MI 48826-0950

Michigan Medicine, the official magazine of the Michigan

State Medical Society (MSMS), is dedicated to providing

useful information to Michigan physicians about actions

of the Michigan State Medical Society and contemporary

issues, with special emphasis on socio-economics,

legislation and news about medicine in Michigan.

The MSMS Committee on Publications is the editorial

board of Michigan Medicine and advises the editors in

the conduct and policy of the magazine, subject to the

policies of the MSMS Board of Directors.

Neither the editor nor the state medical society will accept

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Michigan Medicine (ISSN 0026-2293) is the official

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3

March / April 2016 • Volume 115 • No. 2

P R E S I D E N T ’ S P E R S P E C T I V E

Encouraging Physician Roots to Growin Rural Areas of Michigan

BY ROSE M. RAMIREZ, MD

Michigan is a beautiful place to live and even though winter can seem long, the other seasons highlight the paradise we enjoy. We have the Great Lakes,

large swatches of state and federally protected lands and numerous inland lakes and waterways. Much of our state is rural and dotted with small towns from our southern border to the tip of the Keweenaw Peninsula.

When we look at our physician workforce in the state, we see that the densely pop-ulated areas have an abundance of physi-cians, both primary care and specialists, along with state-of-the-art medical facil-ities. However, one of the challenges, es-pecially in the northern lower peninsula and the upper peninsula is having enough physicians to care for residents in those areas. In the rural areas, we sometimes see Federally Qualified Health Centers, staffed by Physician Assistants and Nurse Practitioners. Many of these clinicians are excellent providers and we appreciate their commitment to our rural commu-nities. However, having more physicians in these rural areas, especially well-trained primary care providers (family medicine, internal medicine and pediatricians) will enhance our ability to improve quality and address population health. How do we get more of these doctors to settle in rural communities to practice and raise their families there?

4 MICHIG AN MEDICINE March / April 2016

P R E S I D E N T ’ S P E R S P E C T I V E

Doctor Ramirez, a Kent County family physician, is president of the Michigan State Medical Society

Certainly, loan forgiveness and financial incentives help to get physicians to go to rural areas to practice, but too often, af-ter the requirements of the incentives are repaid, these physicians move on to other places. The key is to look for ways to iden-tify those most likely to go to a rural area to practice and remain there as a part of the community.

I contacted Andrea Wendling, MD, Asso-ciate Professor and Director of the Rural Medicine Curriculum at the Michigan State University College of Human Med-icine (MSU-CHM). Both Doctor Wend-ling and her husband, Mike Harmeling, MD, completed medical school at the University of Michigan, trained at the family medicine residency in Grand Rap-ids and then moved to Boyne City to join a practice. Despite her practice in a rural community, she has pursued her academ-ic interests. She has written grants to get funding for rural physician training and has published original research on training rural physicians.

She shared with me that “MSU-CHM has been creating, sustaining and studying in-novative approaches to rural medical edu-cation for over forty years. In 1972, MSU-CHM received a Federal Bureau of Health Manpower Grant and Michigan legislative funds to develop one of the nation’s first rural training programs, the Upper Pen-insula Rural Physician Program (RPP).”

Based on the success of the program head-quartered in Marquette and the ongoing need for rural physicians in our state, two campuses in rural regions of the lower pen-insula were developed in 2012. The same model was used which offers earlier rural experiences and a more robust clinical curriculum. Leadership experiences were promoted by development of student-led community-based scholarly projects and partnerships with rural Public Health De-partments. In addition to these training programs, MSU-CHM has developed the Rural Premedical Internship Program, an undergraduate pipeline program targeting students of rural origin interested in med-ical school.

I recently met with State Representative, Edward J. ‘Ned’ Canfield, DO. He is from 84th District which covers Huron and Tuscola counties (the thumb area of our state). He introduced legislation in the House late in 2015 to oppose Mainte-nance of Certification requirements by hospitals and payers. That legislation is currently assigned to the House Health Policy committee.

Representative Canfield is acutely aware of the projected shortages in the physician workforce in our state and he is working on an innovative proposal to engage medi-cal students and provide tuition relief in re-turn for practice in a rural or underserved area of our state. He thinks that if students

already show a desire or interest in primary care and rural practice, and if the tuition cost can be offset, this will make it easi-er for these students to seriously consider rural practice. More to come on this one!

I grew up in a small town about 30 miles ENE of Grand Rapids, Michigan. My doctor was a general practitioner and was a beloved member of our community. He delivered babies, made house calls and had a busy practice. One Christmas, my father had just had surgery on his back and was out of work. Doctor Louis Sanford sent gifts to our home for me and my four younger siblings. I was in third grade I be-lieve, and he gave me a stuffed kitten made from soft white rabbit fur. It made a lasting impression! These are the stories we love to hear, and that continue to come from our small Michigan communities.

Thirty Years Training Rural Physicians: Outcomes from the Michigan State University College of Human Medicine Rural Physician Program. Wendling, et al. Academic Medicine, Vol 91., No. 1/ January 2016.

Volume 115 • No. 2 MICHIG AN MEDICINE 5


In my experience the State frequently “overcharges” physicians in Administrative Complaints. Often allegations of negligence, lack of competency and other defamatory violations of the Public Health Code are included when there is only evidence to support (which is readily admitted at the compliance conference) much more minor violations (e.g. a failure to document). The overcharging can be personal as well as professional (e.g. alleging a licensee has a substance abuse disorder which makes him/her a danger to patients based only on the only DUI conviction ever received by the licensee which occurred during non-business hours).

Taking advantage of the compliance conference process is wise (the only alternative is an expensive administrative hearing). However, it is more important than ever to pay attention to the wording of the Consent Order and Stipulation. The public and your patients will have access to this document. If all agree at the compliance conference that there was no negligence or incompetence and instead that you only failed to include adequate documentation in your medical records then the Consent Order and Stipulation should clearly indicate this.

If the State refuses to agree to language stating that there was no finding that you were negligent or lacked competency you should seriously consider going to an administrative hearing where the State will be required to prove these allegations (and its failure to do so will be just as public as its success in doing so).

A S K O U R L A W Y E R

QUESTION:

I was investigated by the State of Michigan following a patient complaint. An Administrative Complaint was filed against me al-leging that I was negligent, lacked competency, billed for services improperly and that I had violated several other provisions of Michi-gan’s Public Health Code. My lawyer and I met with an attor-ney general and a representative of the Board of Medicine at a com-pliance conference. We all agreed that my only failure was to fully document the reasons for my diag-nosis and treatment of this patient. A sanction of probation with some medical record documentation continuing education was agreed to. Is there a way to make this set-tlement/sanction confidential?

Daniel Schulte, JD, MSMS Legal Counsel, is a member of Kerr Russell Attorneys and Counselors

Greater Publication of State DisciplinaryActions Makes Compliance Conference

Settlements More DifficultBY DANIEL J. SCHULTE, JD, MSMS LEGAL COUNSEL

ANSWER: Unfortunately no. MCL 333.16216(6) requires that the Michigan Department of Licensing and Regulatory Affairs (“LARA”) include on its public licensing and registration website each “final decision that imposes disciplinary action against a licensee, including the reason for and description of that disciplinary action.” This statute was amended effective January 1, 2015 expanding the information that is required to be made available to the public.

To comply with this requirement, LARA has been including links to copies of both the Administrative Complaint and the Consent Order and Stipulation agreed to following a settlement at a compliance conference on its website that is available to the public. Because these documents are now routinely being made available to the public in an easily accessible way it is more important than ever to insist the language of any Consent Order and Stipulation you agree to accurately reflect what was decided at the Compliance Conference.

The compliance conference process is an excellent way to meet informally with the attorney general and the Board of Medicine member responsible for your case. At these conferences (which are confidential) you have the opportunity to view all the evidence the State has obtained in its investigation, hear how the Board of Medicine and any expert the State has retained views the situation, offer an explanation for your acts or inaction and to agree how the case should be resolved (i.e. what the sanction, if any, should be). Any agreement reached at a compliance conference is documented in a Consent Order and Stipulation.


A S K O U R L A W Y E R


M D H H S U P D A T E

Over a Third ofYoung Children in MichiganAre Susceptible to Vaccine

Preventable Diseases CRISTI BRAMER, MPH, MCIR EPIDEMIOLOGIST,

MDHHS DIVISION OF IMMUNIZATION

Before children are two years of age, the Advisory Committee on Immunization Practices (ACIP) recommends vaccination to prevent14 infectious diseases: measles, mumps, rubella, varicella, hepatitis A, hepatitis B, diphtheria, tetanus, pertussis, Haemophilus influenzaetype B (Hib), polio, influenza, rotavirus, and invasive pneumococcal disease.

Vaccines are our best defense against these infections, which may cause serious complica-tions, even death. A Centers for

Disease Control and Prevention (CDC) analysis conducted in 2014 concluded that routine childhood vaccination will prevent 322 million cases of disease and about 732,000 early deaths among children born during 1994–2013 in the United States.1

To monitor immunization coverage among children aged 19 through 35 months in the United States, the CDC conducts the National Immunization Survey (NIS). The NIS is a telephone survey of parents followed by a mailed survey to children’s immunization providers that began data collection in 1994. When the first NIS data were released, Michigan had the lowest im-munization coverage in the nation. In re-sponse, we implemented several initiatives to increase immunization coverage includ-ing, but not limited to, immunization cam-paigns (Immunize Your Little Michigan-der), the Michigan Advisory Committee on Immunization (MACI), and development of the statewide immunization registry (the Michigan Childhood Immunization Regis-try, now the Michigan Care Improvement Registry, or MCIR). The federal Vaccines for Children (VFC) program, launched in 1994, supported our efforts to increase chil-dren’s vaccination rates.

Michigan’s immunization coverage subse-quently increased and in the past 20 years we have not ranked at the bottom of the NIS standings again – in fact, in 2009 and 2010 we had the 5th highest coverage in the nation. On August 28, 2015, data from the 2014 NIS survey were released and Michi-gan was ranked 47th in the nation with 65 percent vaccination coverage; the survey re-ported a 5 percent decrease in coverage from


M D H H S U P D A T E

Serving healthcare providersfor over 30 years

the 2013 point estimate.2 While there are limitations to surveys, the MCIR has become a reliable tool for assessing childhood vacci-nation coverage and these data also show a slight decrease in 19 through 35 month vac-cination coverage.

Following the release of the 2014 NIS data, the MDHHS Division of Immunization has endeavored to understand why immu-nization coverage is dropping in Michigan’s children. An increasingly complicated vac-cination schedule, increased number of vac-cines recommended, alternative vaccination schedules, and a reduction of VFC providers are some of the challenges faced by today’s immunization providers and parents.

MCIR data show that many children in Michigan are not receiving their vaccines on time. To help pinpoint when kids are missing their vaccines we assessed vaccination status for one month cohorts of kids at age 1, 3, 5, 7, 16, 19 and 24 months; these ages corre-spond to the end of a recommendation pe-riod for one or more vaccines. As of January 17, 2016, only 70.9 percent of kids 3 months

of age were up-to-date for their recommend-ed vaccines, at 5 months only 65.6 percent kids and at 7 months just over half, 53.2 per-cent, are up-to-date.

National data show that there are two primary factors that contribute to children falling behind from one milestone to the next:

1. Some children DO NOT have a vaccination visit during the time period, and

2. Some children who had a vaccination visit DID NOT receive all of the vaccinations that were due, resulting in missed opportunities for simultaneous vaccination.3

You can use MCIR to assess your practice’s vaccination coverage. There are also existing educational resources available to provider of-fices, including free immunization nurse ed-ucation sessions and the Physician Peer Ed-ucation Project on Immunization, and both are approved for continuing medical educa-tion credit (visit www.aimtoolkit.org – click on “health care professionals” and “education

and trainings”). You can find your county’s immunization coverage on the county immunization report cards (available at www.michigan.gov/immunize - click on “Local Health Departments”).

A variety of new strategies are being ex-plored by MDHHS to increase vaccination coverage. We encourage you to ensure that all of your patients are protected from vac-cine-preventable diseases and to implement evidence-based strategies for increasing im-munization rates in your practice (see http://www.thecommunityguide.org/vaccines/in-dex.html).

REFERENCES1 Whitney CG, Zhou F, Singleton J, Schuchat A. Benefits from immuni-zation during the Vaccines for Children program era—United States, 1994–2013. MMWR Morb Mortal Wkly Rep 2014;63:352–5.2 Hill HA, et al. National, State, and Selected Local Area Vaccination Coverage Among Children Aged 19-35 Months – United States, 2014. MMWR Morb Mortal Wkly Rep 2015; 64(33);889-896.3 Luman, Elizabeth, PhD, Chu, Susan, PhD, MSPH. When and Why Children Fall Behind with Vaccinations: Missed Visits and Missed Op-portunities at Milestone Ages. Am J Prev Med 2009;36(2);105–111.

http://www.aimtoolkit.org

http://www.michigan.gov/immunize

http://www.thecommunityguide.org/vaccines/index.html



http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6316a4.htm






Telemedicine continues to evolve as an innovative means of providing patients with enhanced

access to quality medical care through the use of technology in medically appropriate

circumstances, as an alternative to conventional in-person encounters. Although there is

no universal definition, “telemedicine” is often used to describe the furnishing of clinical health care

services to patients from distant sites through the use of electronic information and telecommunications

technologies. Another term, “telehealth,” is commonly used to refer to a wider range of clinical and

non-clinical health services furnished by technology.

H I T C O R N E R

1This publication is furnished for informational purposes only. It does not communicate legal advice by the Michigan State Medical Society or Kerr, Russell and Weber, PLC. Receipt of this publication does not establish an attorney/client relationship. © 2016 Kerr, Russell and Weber, PLC

Read a “Telemedicine in Michigan:What Physicians Need to Know’’ Legal Alert online at www.msms.org/

AboutMSMS/News/tabid/ 178/ID/3820/

Telemedicine-in-Michigan-What-

Physicians-Need-to-Know.aspx

Telemedicine in Michigan: What Physicians Need to Know

BY PATRICK J. HADDAD, JD

KERR, RUSSELL AND WEBER, PLC, MSMS LEGAL COUNSEL1

“Telemedicine,” as defined in the Insurance Code, means “the use of an electronic media to link patients with health care professional in different locations.” To qualify as telemed-icine, the health care professional must be able to examine the patient “via a real-time, interactive audio or video, or both, telecom-munications system” and the patient “must be able to interact with the off-site health care professional at the time the services are pro-vided.” MCL § 500.3476(2).

Importantly, in order for telemedicine ser-vices to be covered by an insurer, HMO, or self-funded plan, the services must comply with all requirements specified by the pay-er, which may choose to cover telemedicine services only in limited circumstances. Phy-sicians will need to check each payer’s cov-erage and reimbursement criteria, including the CPT codes and modifiers which the payer will accept, whether the payer requires prior authorization, whether physicians are prohibited from billing patients for telemed-icine services if not covered by the payer, and whether the payer has established additional standards that must be satisfied as a condi-tion of payment.

Limitations on Commercial Health Plan Coverage for Telemedicine ServicesThe Michigan Insurance Code was amend-ed in 2012 to facilitate coverage for tele-medicine services. The Insurance Code prohibits health insurers and HMOs from requiring face-to-face contact between a health care professional and a patient for services appropriately provided through telemedicine, as determined by the insurer or HMO. Telemedicine services must be provided by a health care professional who is licensed, registered, or otherwise lawful-ly authorized to engage in his or her health care profession in the state where the pa-tient is located. Telemedicine services are subject to all terms and conditions of the policy, certificate, or contract covering the patient including, but not limited to, re-quired copayments, coinsurances, deduct-ibles, and other approved amounts. MCL § 500.3476(1).

https://www.msms.org/AboutMSMS/News/tabid/178/ID/3820/Telemedicine-in-Michigan-What-Physicians-Need-





H I T C O R N E R

Priority Health’s telemedicine policy il-lustrates how some payers approach tele-medicine. Under Priority Health’s policy, evaluation, management and consulta-tion services using synchronous (i.e., real time) technologies may be considered medically necessary when all of the fol-lowing conditions apply:

• The patient must be present at the time of consultation; and

• The consultation must take place via an interactive audio and/or video telecommunications system and the provider must be able to examine the patient in real-time. Interactive telecommunications systems must be multi-media communication that, at a minimum, include audio equipment permitting real-time consultation with the patient and the consulting practi-tioner; and

• A permanent record of telemedicine communications relevant to the ongo-ing medical care of the patient should be maintained as part of the patient’s medical record; and

• Services delivered through a tele-medicine modality shall be provided by a health care professional who is licensed, registered, or otherwise authorized to engage in his or her health care profession in the state where the patient is located; and

• Appropriate informed consent is obtained which includes all of the information that applies to routine office visits as well as a description of the potential risks, consequences and benefits of telemedicine.

Priority Health specifies other criteria for evaluation and management ser-vices furnished by asynchronous tech-nologies (which Priority defines as any type of online patient-provider consul-tation where electronic information is exchanged involving the transmission via secure servers). In addition, tele-monitoring services (i.e., the use of information technology to monitor pa-tients at a distance) are permitted only in specified circumstances.

Priority Health excludes various services from its definition of “telemedicine” services including, but not limited to, the following:

• Administrative services such as appoint-ment/diagnostic test scheduling, or updating patient information;

• Store and forward telecommunication;• Brief patient interactions such as requests

for a referral, clarifying simple instruc-tions, providing education materials, re-porting normal test results, or refilling or renewing existing prescriptions without a substantial change in clinical situation;

• Brief patient discussions to confirm the stability of a patient’s chronic condi-tion or condition following a medical procedure without any change in current treatment or without indication of com-plication or new condition;

• When information is exchanged and fur-ther evaluation is required such that the patient is subsequently advised to seek face-to-face care within 48 hours; and

• Services that would similarly not be charged for in a regular office visit.


Blue Cross Blue Shield of Michigan and Blue Care Network have announced two initiatives for telemedicine services. Both organizations have contracted with Ameri-can Well® to provide online physician vis-its to members using the Amwell™ online health care technology. This is available to members of self-funded groups which have opted to receive this benefit effective Janu-ary 1, 2016. BCN fully insured individual and group members will also have this ben-efit effective January 1, 2016. Blue Cross will expand its offerings to include fully insured individual and group members ef-fective July 1, 2016. This benefit presently is not available to Medicare or Medicaid members.

The other initiative is for physicians who are not affiliated with American Well®. Blue Cross Blue Shield will provide reimburse-ment to providers credentialed to perform evaluation and management services for HIPAA-compliant online services for mem-bers of any self-funded group that opts in as of January, 2016. After July 1, 2016, the code will be reimbursable to Blue Cross pro-viders for all insured individual and group members. Blue Cross will keep physicians and other providers informed in The Record.

Blue Care Network has established its own special guidelines:• Participation is limited to primary care

physicians.• Online visits can be conducted with

established patients only.• Special software must be used to

structure an automated clinical encounter. Online visits are not covered for BCN AdvantageSM members.

• For Healthy Blue LivingSM HMO members, online visits cannot be used for the initial visit required to complete the Blue Care Network Qualification Form, but can be used for other visits, as appropriate.

• For online visits, all physician consultative services must be documented in the member’s medical record. BCN reserves the right to audit these records and confirm billing integrity and accuracy. Online visits are subject to retrospective review.

More information and billing guidance related to BCN participating providers is available in the Claims section of the BCN Provider Manual.

itan Statistical Area. Claims to Medicaid for telemedicine services also use the tele-medicine modifier GT. Procedure code and modifier information is contained in the MDHHS Telemedicine Services Database available on the MDHHS website. Dis-tant site providers (i.e., physicians or other licensed practitioners) must be enrolled in Michigan Medicaid.

There are no prior authorization require-ments when providing telemedicine services for Medicaid fee-for-service beneficiaries. However, authorization requirements for beneficiaries enrolled in health plans con-tracted to the Michigan Medicaid Program may vary. Physicians and other practitioners must check with individual Medicaid health plans for any authorization, coverage or other requirements.

RECOMMENDED PRACTICES Listed below are recommended practic-es and issues which Michigan physicians should be aware of when furnishing tele-medicine services. Practices and issues are not presented in any order of priority.

• Use Telemedicine in Medically Appropriate Circumstances. Telemedicine should be used only in medically appropriate circumstances. To mitigate professional liability and licens-ing risk exposures, physicians should not use telemedicine when the prevail-ing medical standard of practice calls for an in-person encounter. In the event of medical emergencies, patients should be directed to hospital emergency rooms or to dial 911.

• Licensing Compliance. A physician or other health care professional must be licensed, registered or otherwise au-thorized by law to engage in his or her health care profession in the state where the patient is located.

• Prescribing Medications Generally— Michigan Law. Physicians must exercise professional judgment and discretion before deciding whether to prescribe medications on the basis of a telemed-icine encounter. There must be an existing and valid physician/patient relationship. Michigan is one of a hand-ful of states that do not, by statute or regulation, mandate an in-person exam-ination before a physician may prescribe medications. Nevertheless, a physician

Medicare and Medicaid Telemedicine Standards MEDICAREMedicare Part B will reimburse for qual-ifying telemedicine services only in lim-ited circumstances. Telemedicine services must be furnished by a licensed physician or other practitioner (i.e., the distant site practitioner) to an eligible beneficiary via an interactive audio and video telecom-munications system that permits real-time, face-to-face interactive communication be-tween the physician and the patient. Medi-care beneficiaries are eligible for telemedi-cine services only if they are presented from an originating site located in a rural health professional shortage area located either outside of a Metropolitan Statistical Area or in a rural census tract, or in a county outside of a Metropolitan Statistical Area. Eligible originating sites include the offices of physi-cians or practitioners; hospitals; critical ac-cess hospitals; rural health clinics; federally qualified health centers; hospital-based or CAH-based Renal Dialysis Centers (includ-ing satellites); skilled nursing facilities; and community mental health centers. Howev-er, independent renal dialysis facilities are not eligible originating sites. Telemedicine services must be furnished by a qualified practitioner at a qualifying originating site (e.g., physician offices, hospitals, skilled nursing facilities). 42 C.F.R. § 410.78.

The Centers for Medicare & Medicaid Ser-vices annually revises Medicare’s standards for reimbursement for telemedicine ser-vices. When submitting claims to Medi-care for telemedicine services, physicians and other practitioners will need to use the appropriate CPT or HCPCS code for the professional service along with the telemed-icine modifier GT, “via interactive audio and video telecommunications systems.” Medicare’s list of covered telemedicine ser-vices is available on the CMS website.

MICHIGAN MEDICAID PROGRAM The Michigan Medicaid Program imposes similar limitations on telemedicine as Medi-care, with some differences. While Michi-gan Medicaid’s list of eligible originating sites is similar to Medicare’s, Michigan Medicaid does not require an originating site to be located either outside of a Metro-politan Statistical Area or in a rural census tract, or in a county outside of a Metropol-


may have an exposure to a professional liability claim, as well as a licensing ac-tion, if the standard of medical practice would require an in-person examination before prescribing medication. In con-trast to prescriptions issued pursuant to a bona fide telemedicine encounter, the Michigan Board of Pharmacy, the Na-tional Association of Boards of Pharma-cy, and the Federation of State Medical Boards all consider prescriptions issued pursuant only to an internet question-naire to be invalid, because there is no existing physician-patient relationship when the physician and patient have not interacted except on the basis of an online questionnaire.

• Prescribing Medications Generally—American Medical Association Policy Guidelines. AMA policy guidelines provide that a patient-physician rela-tionship generally must be established before medication can be prescribed through a telemedicine encounter. The physician must (i) obtain a reliable medical history and perform a physical examination of the patient, adequate to establish the diagnosis for which the drug is being prescribed and to identify underlying conditions and/or contrain-dications to the treatment recommend-ed/provided; (ii) have sufficient dialogue with the patient on treatment options, risks and benefits; (iii) as appropriate, follow up with the patient to assess the therapeutic outcome; and (iv) maintain a contemporaneous medical record, including the prescription information. If telemedicine technology is used to establish a physician-patient relation-ship, a video component is needed to facilitate a face-to-face encounter which is necessary to prescribe medications; ordinary telephone calls and email com-munications are insufficient. Exceptions to the above requirements can arise in on-call or cross-coverage situations, emergency medical treatment, in other circumstances recognized as meeting or improving the standard of care, or when medication is prescribed in consultation with another physician who has an on-going professional relationship with the patient and who has agreed to supervise the patient’s treatment, including use of any prescribed medications.

• Prescribing Medications—Controlled Substances. Physicians must exercise caution before prescribing controlled substances during a telemedicine en-counter, in light of intentionally restric-tive U.S. Drug Enforcement Adminis-tration compliance obligations and law enforcement risks designed to combat unlawful diversion and internet mills. A prescription for a controlled substance cannot be lawfully prescribed on the basis of a telemedicine encounter unless the prescribing physician has conducted at least one (1) in-person medical eval-uation of the patient, subject to limited exceptions that will not be available to most physicians and other prescribers. An “in-person medical evaluation’’ means a medical evaluation that is con-ducted with the patient in the physical presence of the practitioner, without regard to whether portions of the eval-uation are conducted by other health professionals. Even if the minimum one (1) in-person encounter requirement is satisfied, the prescription must be issued for a legitimate medical purpose in the usual course of prescriber’s professional practice, which are longstanding legal requirements applicable to all prescrip-tions for controlled substances. Federal law provides that nothing is construed to imply or suggest that a one (1) in-person medical evaluation demon-strates compliance with these standards; i.e., all of the facts and circumstances surrounding the issuance of the pre-scription must be evaluated. Prescribers who fail to comply with the in-person medical evaluation requirement, and any pharmacy that knowingly or inten-tionally fills such a prescription, violate the Controlled Substances Act.

• Professional Liability Insurance Coverage. Physicians should review their professional liability policies to confirm coverage for telemedicine services or whether exclusions may apply. The insur-er or insurance agent should be contacted as needed and to determine whether the insurer has any recommended risk man-agement practices.

• Informed Consent. As in any conven-tional encounter, informed consent must be obtained with respect to a telemedicine encounter. Michigan is one of several states which, by statute or regulation do not expressly require

a patient’s informed consent in order to furnish services via telemedicine. However, physicians remain responsible to ensure that patients are aware of the potential benefits and risks associated with receiving services via telemedicine, and that the patient consents to receiv-ing services via telemedicine. Evidence of the patient’s informed consent should be maintained in the patient’s medical record, as is the case for a conventional encounter.

• Maintain Medical Records for Telemed-icine Services. Michigan licensed physi-cians are obligated to maintain medical records for telemedicine services as they would for any conventional, face-to-face encounter. There is no exception from professional liability or licensing risks for failure to do so.

• Comply with Third Party Payer Billing Requirements. Before furnishing and billing payers for telemedicine services, physicians need to understand and to comply with each payer’s requirements. In general, each payer has the right to establish its own terms and conditions.

• Mitigate Post Payment Audit Risks. As in any encounter, it is critical for physicians to accurately document in the clinical record all clinical and other information required to substantiate the claim as coded and billed. Physicians furnishing services by telemedicine are exposed to post payment audit risks as they are for services furnished during conventional encounters.

• Use HIPAA Compliant Technology which is Reliable. Physicians are responsible to comply with HIPAA’s privacy and security rules when furnishing telemed-icine services. Physicians should verify whether their telecommunications vendors use HIPAA compliant technol-ogy. In addition, the technology must be reliable. If the telecommunications equipment is defective or otherwise fails during a patient encounter, the patient or physician may receive inaccurate in-formation, which could result in injury to the patient. Physicians should seek to negotiate vendor responsibility within their contracts to encourage a high level of technology performance. In addition, physicians should determine whether they have liability insurance coverage in such circumstances.


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which removes the administrative burden from you and your staff;• Will research claims inquiries and benefit questions for you or the subscriber, which will eliminate the frustration

of contacting a complex customer service center; and,• Handles all COBRA administration for groups with more than 20 employees, free of charge, thus removing

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For more information or to request a quote for affordable, high-quality health insurance, please connect with Beth at 877/742-2758 or [email protected].

www.MSMSInsurance.org


My objective today is to report on the status of the Michigan State Medical Society Alliance and our works in progress.

As an Alliance of physician spouses and partners, we work for the common good of our communities, our families, and the profession of medicine. Our 16-county state Alliance is an important link in the National Federation (AMAA) with whom we share the com-mon mission of improving the health and wellness of all our citizens. Unfortunately, we also share a common concern—that of shrinking membership. For example, Saginaw is exploring a union with Midland and Kalamazoo is merging with Calhoun, while Muskegon is on hiatus. Nevertheless, we forge ahead.

Immunization: A Major ConcernIn 2013, we learned that Michigan ranked 48th among the 50 states in Childhood Immunization. Our Alliance went to work. While the dismal statistics were unaccept-able, the greater shock was to learn that our “best educated” citizens were the least likely to be current on vaccinations of their own children. In fact, the state of Michigan made it all too convenient for parents to opt out of vaccinating their children—thereby putting both their children and their com-munities at risk.

In order to have an impact, education on childhood immunization must begin at an early stage. Former MSMSA President Cindy Ackerman and MSMSA Legisla-tive Chairman Karin Maupin continue to make advances with an Educational Ini-tiative on Immunization. During Cindy's presidency (2013-14), the MSMS Founda-tion approved an education grant to Mich-igan counties for the purpose of dispelling the many dangerous myths surrounding childhood immunizations. Based on pos-itive feedback to their several statewide seminars on the subject of childhood im-munization, they were able to channel the remaining funds to a committee charged with finding the most effective means of educating the public.

Two ideas are currently being explored:(1) to give every new-birth mother a

“growth chart” showing information on the vital need for and optimal tim-ing of immunizations, and

(2) to provide doctor’s offices with post-ers on childhood immunization. The MSMSA would be responsible for dis-tributing the charts and posters to all counties.

About a year ago, the Alliance joined the Immunization Stakeholders Group, re-cently renamed the Parent Information Network. Commonly known as PIN, this group, together with Michigan Public Health and Human Services, concluded that it is in the public interest to insti-tute a policy change to ensure that all children are up-to-date on vaccinations before they can even attend school. As of the start of each school year, parents who want a waiver from vaccinations must now go to their local Public Health De-partment to get educated. If their child has not been vaccinated, he or she can-not attend school. Period. Just as in most countries in the developed world.

Initial results are indeed impressive. In 2014, 4.6% of schoolchildren in the state received immunization waivers. In 2015, that rate fell to 2.8%, or nearly 8,000 fewer waivers.

Report on the Status of theMSMS Alliance Works in Progress

BY CLARA SUMEGHY, PRESIDENT, MSMS ALLIANCE

M S M S A L L I A N C E

“The primary tool for advancing our mission is advocacy. Thus, in partnership with you and the AMA Alliance we continually work to develop, implement and support educational programs that benefit public health. We also serve as a resource for our County Alliances. Through advocacy, we try to inform our Legislature, as well as our own Alliance Members, about issues that may have an impact on public health and/or the practice of medicine.”


Despite the progress achieved thus far, we still have an uphill battle to counter the misinformation and ignorance regarding immunizations. For example, Lansing Representative Thomas Hooker has in-troduced legislation (HB 5126 and HB 5127) to prohibit the MDHHS from enforcing waiver requirements that are not mandated by state law, including the aforementioned educational discussions on immunization. His proposed legis-lation would also prohibit local health officials from pulling a non-immunized child out of school even under the threat of a communicable disease — unless that threat amounts to an epidemic. This is just one egregious example of why our continuing support and involvement in the PIN is vital.

In response, Alliance members through-out the state participated in a letter-writ-ing campaign to all members of the Health and Policy Committee urging lawmakers to reject the Hooker Bills. This dangerous legislation could effectively reverse the positive impact on Michigan’s improved childhood immunization rate. It must be defeated.

We are now waiting to learn when the Hooker Bills will be scheduled for a pub-lic hearing by the House Health Policy Committee. Our Alliance, of course, is ready to mobilize to attend this hearing.

In related news, on January 28, the DHHS released their highly-anticipat-ed report on the effectiveness of the new rules regarding school-children-immu-nization waivers. That same morning, PIN coordinated four simultaneous press conferences in Lansing, Grand Rapids, Southfield, (southeast Michigan) and Traverse City. Physicians talked about the importance of immunizations, health de-partment officials discussed the decline in waiver rates, and parents shared their fam-ily experiences. Our Alliance members were present to show our strong support to the participants.

In addition to the Immunization issue, we are working closely with MSMS staff to remain current on legislation requiring our Alliance’s assistance. To further this objective, we plan to hold an “Alliance Legislative Day at the Capitol” in March.

Awards & EventsIn June 2015, at the AMA Alliance (AMAA) Annual Meeting in Chicago, our Alliance won 3 out of 6 possible awards. This was the first time that any one State Alliance received three AMAA awards. Moreover, one County Alliance managed to take 2 First Place awards.

Kent County Medical Society Alliance received the AMAA Health Awareness Promotion Fund-raising County Award. First Place: “Children’s Charity Ball” — chaired by KMSA presi-dent elect Karen Begrow

Kent County Medical Society Alliance received the AMAA Legislative Education & Awareness Promotion Award. First Place: “Immuniza-tion Conference” — chaired by KMSA President Elizabeth Junewick

Tri-County Medical Society Alliance received the AMAA Health Awareness Promotion New Projects Award. Honorable Mention: “De-ciphering Facts and Myths About Child-hood Immunizations” booklet

In addition to the preceding awards, we cannot forget the groundbreaking work in 2014 by the Genesee County Alliance in bringing the problem of Human Traf-ficking in Michigan to public notice. They were recognized by the AMAA in Chicago with Honorable Mention by the AMA Alliance HAP (Health Promotion) Award. Through their annual seminars, they continue to advance this important work.

On October 7, 2015, I attended the 150th Anniversary of the Michigan State Medical Society. Our Alliance was honored and pleased to participate in predicting the course of medicine during the next 50 years. It would be fun, though quite un-likely, to see the results of our predictions in 2065. But, with the speed of scientific advances, who knows?

Governor Rick Snyder declared October 14, 2015 as “SAVE Today,” and presented the Al-liance with the Certificate of Proclamation during our “SAVE” (Stop America’s Vi-olence Everywhere) campaign’s 20th an-niversary celebration in Lansing. Julie Novak has kindly framed the certificate, which is now hanging downstairs in the newly-decorated Alliance Room, along-side other Alliance accolades.

Other County NewsWashtenaw County collected over 100 bags of personal items for Safe House, their do-mestic violence shelter in Ann Arbor. They also obtained a proclamation for ‘Save Day’ from Mayor Christopher Taylor of Ann Arbor.

Ingham County hosted a luncheon follow-ing a period of several years’ inactivity. For their ‘SAVE Day’ shelter, they also collect-ed much needed over-the-counter medica-tions.

In October, Marquette Alger County held their 10th annual Shower for Harbor House, the local domestic violence shelter. In addition to household furnishings, they collected $1,700.

Saginaw County held their annual ‘Jingle Mingle’ fundraising event on Dec 7. With help from the Saginaw Medical Society, they raised $3,500 which will provide scholarships of $500 each to seven nursing students. In addition, they collected bags of personal care items for their Commu-nity Center.

Oakland County and Jackson County collect-ed bags of personal care items for their Domestic Shelters.

Wayne County obtained a proclamation for ‘Save Day’ from Warren C. Evans, Wayne County Executive. They also contributed $500 to WCMSSM Foundation’s Annu-al Children’s Holiday Party held Dec 12, 2015. The children also received a copy of each AMAA booklet: Hands Are Not For Hitting; I Can Be Healthy; I Can Choose; and, I Can Handle Bullies.

Finally, Kent County just held their annual Children’s Holiday Party on Jan 30 capping a successful fundraising year with $100,000 in 2015.

In conclusion, our Medical Alliance as always will continue our work to advance the health of Michigan through advocacy and action. Together we can accomplish much.

M S M S A L L I A N C E


Rural Practices:Founded in Family

and Community

From Monroe to Marquette, when it comes to practicing medicine in a rural area of Michigan, our physicians see their job

not as a challenge, but an opportunity to care for people who need it the most.


Volume 115 • No. 2 MICHIG AN MEDICINE 19Volume 115 • No. 2 MICHIG AN MEDICINE 19

Monroe Family Legacy

When John Pasko, MD, started with medical school then residency in Wayne State University/DMC, he set out to care for the most in need. Doctor Pasko explains, “Coming back to Monroe, my hometown, allows me to care for people who live in the community where I grew up. Living in and being a part of this culture helps me

to care for people better. My care is timely, appropriate and given in the context of when, where and how my patients live”

Doctor Pasko’s father, John E. Pasko, MD, a General Surgeon, practiced for over 40 years in Monroe and his mom, Rosalie Pasko, was a Medical Technologist for over 25 years at their local hospital. Doctor Pasko says, “My family, growing up, was a part of the local culture and medical community. I have heard stories from many long-time residents about how my dad cared for them when they were in need.”

Doctor Pasko emphasizes the importance of having support from like-minded specialists, especially in underserved regions. “I share an office with my wife, Laura Katz, MD, a solo OB-GYN and minimally invasive robotic surgeon. She helps give birth to babies then I take over from there. It is a holistic and family-centered approach to care and one that I would not trade for the world.”

Although Monroe is a small community, Doctor Pasko has become involved in several groups and initiatives that benefit the community and help him become a better physician. Doctor Pasko sits on the board of Monroe Alliance of Physicians (MAP). Being heavily involved in the group allows him to continue his practice as a solo physician while using the collective bargaining power of his colleagues to negotiate with insurance companies. Doctor Pasko explains, “MAP helps me stay in touch with a larger world of incentives for value-driven care.”

MONROE


JOHN PASKO, MD LAURA KATZ, MD

Marquette-based Dream Team

Christopher Dehlin, MD, and Jennifer Dehlin, MD, longtime Marquette residents and practicing physicians are very aware of the challenges that come along with practicing in a rural, underserved area of Michigan. Doctor Jennifer Dehlin explains, “Most specialty groups up here are small, and so provider turnover can result in significant patient access

issues. For example, the wait time to see a psychiatrist in Marquette right now is one year. As a result, the primary care physicians need to work to the edge of their comfort zones to take care of people”

Though the couple recognizes the challenges of practicing in Marquette, they could not imagine being anywhere else. With family in the area and several nearby towns, it is very important to them to be home. They also take advantage of the outdoor sports available in Marquette. Doctor Christopher Dehlin adds, “We have world-class Nordic and mountain bike trails, we’re seven minutes from our ski hill and five blocks from the beach.”

As a team, Doctors Christopher and Jennifer Dehlin have recently filed paperwork to start their own medical practice in Marquette - Singletrack Health PC. In partnership with Stevens Hardie Family Practice they will offer the full scope of family medicine including inpatient, outpatient, nursing home and obstetrical services.

Doctor Jennifer Dehlin explains what inspired them to make this move, “We think that as health-care delivery evolves we will be better prepared for changes if we are running a small, nimble, high tech practice. We’ve been surprised by how enjoyable it’s been to work with other professionals in the community to get our business started and the support and encouragement from area physi-cians and the hospital.”

MARQUETTE


CHRISTOPHER DEHLIN, MD JENNIFER DEHLIN, MD


State Resources for Rural Physicians

The federal government recognizes Health Profes-sional Shortage Areas (HPSA) and Medically Un-derserved Areas and Populations (MUA/P) in Mich-igan, which are visualized in maps found on their

website. The maps show “designated” HPSA and MUA/P areas throughout the state. These designations are used to determine eligibility for state and national programs. In addition to provid-ing the HPSA map, the federal Health Resources and Services Administration (HRSA) provides a service allowing physicians and residents to verify whether their address is considered part of an HPSA. This tool can be accessed at http://datawarehouse.hrsa.gov/tools/analyzers/geo/ShortageArea.

Along with providing resources to identify underserved areas, the state of Michigan recognizes the importance of supporting rural physicians and offering them with the programs and as-sistance they need to be successful and best serve their patients. The following programs are designed to support rural physi-cians and their practices:

➤ Conrad State 30 Program Under the Conrad State 30 Program, Michigan accepts

applications from physicians on J-1 Visas who want to waive the two-year home residence requirement in exchange for a commitment of three years of service in an underserved area. Michigan may sponsor up to 30 physicians each fiscal year. Priority is given to safety net providers, primary care physi-cians and placements in Health Professional Shortage Areas.

Go to www.michigan.gov/conrad30 for more information.

➤ MSMS Medical Opportunities MSMS Medical Opportunities, a job search website designed

to connect physicians directly with private practice and hos-pital employers, is a partnership with the Michigan Health Council. Physicians register for free on the site and can make themselves available to employers or just browse the job mar-ket. Posted job opportunities include detailed information on the community, practice environment, employer size and ben-efits offered. Recruiting resources are also available for private practices, critical access hospitals or large health systems.

Go to http://msms.medopps.org for more information.

➤ Michigan Center for Rural Health The Michigan Center for Rural Health (MCRH) assists both

Critical Access Hospitals and Rural Health Clinics. MCRH provides training of on-site recruitment coordinators, rep-resents rural Michigan at conferences, develops site specific marketing, promotes collaboration and helps rural sites navi-gate state and federal loan repayment, as well as the National Health Service Corps Scholar Program and Health Profes-sional Shortage Area status.

Go to www.mcrh.msu.edu/Default.aspx for more information.


➤ Michigan’s Rural Recruitment and Retention Network

The Rural Recruitment and Retention Network (3RNet) web-site lists job opportunities for physicians at Critical Access Hospitals and Rural Health Clinics in rural Michigan. Regis-tering for an account with 3RNet is free and allows physicians to browse job postings and be contacted about opportunities. Many job opportunities posted on the website are eligible for loan repayment.

Go to www.3rnet.org/locations/michigan for more information.

➤ Michigan State Loan Repayment Program Michigan administers the Michigan State Loan Repayment

Program (MSLRP) to encourage qualified doctors to practice in Health Professional Shortage Areas in Michigan. MSLRP will assist those selected by providing $50,000 in tax-free funds to repay their educational debt in exchange for working in an underserved area for two years. Participants compete for the renewal of the contract of up to three more times for a total of eight years and up to $200,000 in loan repayment. 40 percent of the loan repayment is funded by the state, 40 percent by the federal Health Resources and Services Administration and 20 percent by the participant’s employer.

Go to www.michigan.gov/mslrp for more information.

➤ National Health Service Corps Loan Repayment Program

The federal Health Resources and Services Administration offers the National Health Service Corps (NHSC) Loan Repayment Program for qualified doctors to work at an approved NHSC site in an underserved area. Providers may receive up to $50,000 in tax-free funds to repay their student loans in exchange for a two-year commitment in an underserved area. Participants may apply to extend their service commitment and receive additional funds after completing the initial two-year commitment. Appli-cants will be more likely to be selected for loan repayment if they are employed at approved practice sites with Health Professional Shortage Area scores of 14 or higher.

Go to www.nhsc.hrsa.gov/loanrepayment for more information.

➤ National Health Service Corps Scholarship Program

The federal Health Resources and Services Administration National Health Service Corps (NHSC) Scholarship Program pays tuition, fees, other educational costs and provides a living stipend for students committed to primary care in return for a commitment to work at least 2-years in an underserved com-munity. Service begins in a high-need area upon completion of primary care residency training. Scholarship payments, other than the living stipend, are federal income tax-free.

Go to www.nhsc.hrsa.gov/scholarships/index.html for more information.

➤ National Interest Waiver Program The National Interest Waiver (NIW) Program allows interna-

tional medical graduates to extend their commitment to prac-tice in underserved communities in return for expediting their status as a permanent resident or citizen in the United States. The Michigan Department of Health and Human Services provides letters of support for NIW petitions.

Go to www.michigan.gov/niw for more information.

➤ Rural Health Clinic Certification The Centers for Medicare and Medicaid Services (CMS) pro-

vides certification letters to Medicare participating clinics locat-ed in rural areas that are designated as shortage areas. The main advantage of the certification letter is to receive enhanced Medi-care and Medicaid reimbursement rates.

Go to www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/RHCs.html for more information.


OBITUARIESThe members of the Michigan State Medical Society remember with respect their colleagues who have died.

Gordon Bartek, MDIngham County Medical Society

11/27/15

Frank Cook, MDGenesee County Medical Society

1/11/16

Richard Crissman, MDKent County Medical Society

12/1/15

Martin Daitch, MDWayne County Medical Society

2/1/16

∫ I N M E M O R Y ¢

If you would like to recognize a colleague by making a gift or bequest to theMSMS Foundation in their memory, please contact:

Rebecca Blake, Director, MSMS Foundation, 120 W. Saginaw St., East Lansing, MI 48823phone: 517-336-5729 email: [email protected]

Allan Hoekzema, MDKent County Medical Society

1/2/16

Edward Hollenberg, MDOakland County Medical Society

1/10/16

Francis Locke, MDLenawee County Medical Society

1/20/16

William Nettleman, MDBranch County Medical Society

12/29/15

J. Thomas Powaser, MDWayne County Medical Society

12/10/15

Robert VanderPloeg, MDKent County Medical Society

1/25/16

Roger Wassink, MDKent County Medical Society

1/9/16

msms.medopps.org

Recruiting is hard work. We can help!

MSMS Medical Opportunities connects Physicians and other health providers with Michigan’s health care employers.

• Physician profiles and job searches are free, quick and effective.

• Job posting memberships begin at $500.

For membership information or to schedule a demo of MSMS Medical Opportunities,

contact us at 800/479-1666 or [email protected].


T H E D O C T O R S C O M P A N Y

There’s an App for That: Benefits and Risksof Using Mobile Apps for Healthcare

BY ROBIN DIAMOND, MSN, JD, RN, SENIOR VICE PRESIDENT, PATIENT SAFETY AND RISK MANAGEMENT, THE DOCTORS COMPANY

With over 100,000 mobile health apps now avail-able—in addition to

many new tools that allow phy-sicians to remotely monitor their patients’ conditions—physicians now have to handle an increas-ing amount of constant data and patient information that they did not have in the past. Patients are using mobile apps to monitor their activity levels, track weight loss, improve medication adher-ence, and even track their blood pressure or blood sugar levels. Only 16 percent of healthcare professionals currently use mobile apps with their patients, but 46 percent plan to do so in the next five years.1

Mobile apps offer many potential benefits to doctors and patients• Mobile apps can help patients

self-monitor their conditions and can alert them and their physicians to problems before they become serious medical issues.

• Some of these apps are regulated by the FDA. For example, patients can monitor their heart rhythms with an FDA-approved device that wraps around their iPhone.

Mobile apps can be a tool for patient education • A better-informed patient is more likely

to understand risks and, if there is an adverse event, may be less likely to file a lawsuit.

• Mobile apps help patients remember important information about their healthcare. Patient pamphlets and other educational materials are often lost or forgotten. Patients forget 80 percent of the information they are told and inaccurately remember an additional 10 percent, leaving patients with just 10 percent of the information remembered correctly.

Mobile apps can engage patients in their healthcareMany patients today are interested in be-coming as involved in their care as possible.

One patient engagement platform that connects patients and physicians, Health-loop, markets its product as a way to have very satisfied patients who will publicly share their experience. This platform moni-tors compliance and adherence to the treat-ment plan; checks in with patients, thus eliminating phone calls; collects outcome data; educates and reinforces education; and identifies at-risk patients quickly to reduce readmissions.

But not all of the apps currently on the market are approved or regulated by the FDA, and the use of mobile apps does not come without liability risks. The Doctors Company has not yet seen malpractice suits that involve mobile apps because the use of these apps to monitor patients is fairly new. Malpractice lawsuits may not be filed for several years after the adverse event, so with the increased use of mobile apps for healthcare, we expect there will be lawsuits involving mobile apps in the future.

Physicians could face allegations of failing to educate the patient/family about the risks and limitations of the app or failing to act appropriately if the app goes offline or malfunctions. Product liability, negli-gence, contract law, and even malpractice tort law could be applied to possible causes of action in lawsuits brought because of an injury connected to use of a mobile app.


T H E D O C T O R S C O M P A N Y

Injuries could occur if:• The physician receives information from

a mobile app and does not act on this information. Physicians have a legal duty to review real-time data direct from the patient and respond. Mobile apps raise patient’s expectations of how a physician will act—the patient/family expect that the patient is monitored 24/7 and the physician will respond “within a mo-ment’s notice.” When an adverse event occurs, if a patient believes the physi-cian failed to act on information from a mobile device, the patient might sue. If physicians don’t respond to information from an app, this will be recorded in the metadata, which can be used in court.

• The readings received from a mobile device are wrong and treatment is prescribed based on the wrong data.

Other important considerations

n Consider whether the two-way communication between you and your patient is secure and, therefore, HIPAA/HITECH compliant. Ask the vendor for assurance that the app is HIPAA-compliant and that data is encrypted for security.

n Know the app:

—Vendor information, such as updates, downtime, and critical value alerts.

—How will it interface with your EHR?

—Is the device regulated by the FDA as a medical device?

—Will you get alerts by e-mail or a phone call from the vendor when the app isn’t working?

n Beware of the possibility of lack of security when using public Wi-Fi with the app.

n Clearly communicate and educate the patient/family about the purpose of the app and how and when the data is transmitted to the clinician.

n Avoid assuring the patient that the app will “take care of everything.” Educate the patient/family about the limitations of the app, with specific examples of instructions for the patient to follow. For example, can the algorithm be changed for specific patient needs?

n Identify a contact person within your organization to troubleshoot and be available to address technical problems.

n Have patient/family sign a consent form describing the risks, benefits, and purpose of the app.

n Do not do this alone! Avoid utilizing medical apps without support from your organization.

There are a lot of untested apps on the market that may be unreliable or even dangerous. Apps are also vulnerable to being hacked, resulting not only in potential loss of personal health informa-tion but also in potential malfunctioning of the app.

• Patients rely on technology alone, leading to decreased phone contact with the physician when symptoms arise or there are changes in the condition that require immediate action.

While apps can be useful tools to support a comprehensive care plan, physicians need to educate their patients about the apps’ limita-tions and potential risks.

Consider limiting your patients to one mo-bile app that you agree to monitor. This will make it easier to control the incoming data and help make the best use of the app.

REFERENCES1Easy on those mobile apps: Mobile medical apps gain

support, but many lack clinical evidence. Modern Healthcare.

November 28, 2015. http://www.modernhealthcare.com/

article/20151128/MAGAZINE/311289981/easy-on-those-apps-

mobile-medical-apps-gain-support-but-many-lack. Accessed

December 16, 2015.

Article contributed by The Doctors Company. Visit www.thedoctors.com/ patientsafety for more patient safety articles and practice tips.

http://www.modernhealthcare.com/article/20151128/MAGAZINE/311289981/easy-on-those-apps-mobile-medical-apps-gain-support-but-many-lack



http://www.thedoctors.com/patientsafety

http://www.thedoctors.com/patientsafety


Winter 2016 Education Course Offerings

ON-DEMAND WEBINARS:EDUCATION WHEN YOU WANT IT!Physician Executive Development Programs: • Health Care Law for Physicians in ACOs • Medicaid Issues and Trends:

Outlook for 2014 and Beyond • In Search of Joy in Practice:

Innovations in Patient Centered Care • From Physician to Physician Leader • Inter-Professionalism:

Cultivating Collaboration • Financial Information Analysis, Budget

Development, and MonitoringChoosing WiselyBalancing Pain Management and

Prescription Medication Abuse: Chronic Pain and Addiction

CDL-Medical Examiner CourseLegalities and Practicalities of HIT including: • Cyber Security:

Issues and Liability Coverage • Engaging Patients on Their Own Turf:

Using Websites and Social MediaSummary of the Affordable Care ActHIPAA Security RuleEnd of Life Concerns and ConsiderationsWhat’s New in Labor and Employment LawPreparing for the Medicare Physician

Value-Based Payment ModifierUnderstanding and Preventing

Identity Theft in Your PracticeStepping Up to Stage 2Physician On-line Rating and Reviews:

Do’s and Don’tsPatient Portals as a Tool for

Patient EngagementHealth Care Providers’ Role in Screening and

Counseling for Interpersonal and Domestic Violence: Dilemmas and Opportunities

Opioids & Michigan Workers’ Compensation

Visit www.msms.org/eo for complete listing of On-Demand Webinars.

2016 BILLING AND CODING COURSES

ICD-10 CLEAN-UP Date: Thursday, April 14Time: 9:00 am to 12:00 pm Location: MSMS Headquarters, East Lansing

BILLING FOR NON-PHYSICIAN PRACTITIONERS Date: Wednesday, May 4Time: 9:00 am to 4:00 pm Location: MSMS Headquarters, East Lansing

BILLING 101 Date: Thursday, May 19Time: 9:00 am to 4:00 pm Location: MSMS Headquarters, East Lansing

MSMS/MMBA BILLING WEBINAR SERIESAT NOON ON THE THIRD WEDNESDAYOF EACH MONTH. TOPICS COMING SOON! For ALL Billing and Coding courses…Contact: Stacie Saylor 336-5722 or [email protected]

Intended for: Physicians, billers, coders and billing managers.

For more information or to register on-line: www.msms.org/eo

Questions? Phone MSMS Registrar at 517-336-7581

MSMS LUNCH-N-LEARN SERIES Grab a lunch, click the link, and join us!

These FREE short and interactive monthly online updates are designed to explore key policy issues impacting physicians in the state of Michigan.

It’s more than a presentation… insights are solicited from participants and interaction with our experts is encouraged. For more information and to register for one of our upcoming webinars, follow this link:

www.msms.org/Education/UpcomingWebinars.aspx



Winter 2016 Education Course Offerings Questions? Phone MSMS Registrar at 517-336-7581

EDUCATIONAL CONFERENCES SUPPORTING END-OF-LIFE CARE Date: Wednesday, March 16, 2016

Location: MSMS Headquarters, East Lansing

Intended for: Physicians, nurses, residents, students, and all health care professionals.

Note: Continental breakfast and lunch will be provided.

Contact: Caryl Markzon 517-336-7575 or [email protected]

ANNUAL JOSEPH S. MOORE, MD CONFERENCE ON MATERNAL AND PERINATAL HEALTH

Date: Thursday, May 19

Location: Somerset Inn, Troy

Note: Continental breakfast and lunch will be provided

Intended for: Physicians, nurses, residents, students, and all health care professionals working with women and their infants.

Contact: Marianne Ben-Hamza 517-336-7581 or [email protected]

SPRING SCIENTIFIC MEETING Morning, afternoon and evening clinical courses available

Date: Thursday, May 19 and Friday, May 20

Location: Somerset Inn, Troy

Contact: Marianne Ben-Hamza 517-336-7581or [email protected]

Note: Continental breakfast and lunch will be provided

Intended for: Physicians and all other health care professionals

151ST MSMS ANNUAL SCIENTIFIC MEETING Morning, afternoon and evening clinical courses available

Date: Tuesday, October 25 through Saturday, October 29

Location: Sheraton, Novi

Contact: Marianne Ben-Hamza 517-336-7581 or [email protected]

Note: Continental breakfast and lunch will be provided.

Intended for: Physicians and all other health care professionals

PRACTICE SUSTAINABLITY Details coming soon on this June 2016 conference.

Visit www.msms.org/eo for complete listing of Educational Conferences.

Register online at msms.org/eoor call MSMS at(517) 336-7581for additionalinformation.



Welcome New MSMS Members!Shawna Ruple, MD, MidlandRobyn Sackeyfio, MD, KentMohammed Saleem, MD, GeneseeWilliam Shepard, DO, GeneseeDaniel Shumer, MD, WashtenawSukhpreet Singh, MD, JacksonRobert Smith, MD, MuskegonCheryl Sobocinski, MD, MacombDaniel Spear, MD, KentNicole Sroufe, MD, WashtenawKaren Stacey-Erwin, MD, LenaweeMichael Stargardt, DO, OaklandMichael Sterrett, MD, CalhounTerri Stillwell, MD, WashtenawStephen Swetech, DO, MacombNithin Thummala, MD, WayneIvy Vachon, MD, Marquette/AlgerΩSiddharth Vannemreddy, MD, GeneseeAlice Watson, MD, OaklandMelissa Wei, MD, WashtenawDavid White, MD, OaklandCharles Wilmanski, MD, CalhounDouglas Winstanley, DO, KentSandra Wisebaker, MD, KentDonza Worden, MD, Alpena/Alcona/ Presque IsleMina Zaki, MD, Wayne

11-23 to 1-29-2016Garth Aasen, MD, KalamazooSara Ahmed, MD, WashtenawDesiree Aird, MD, OaklandRita Akaraz-Avedissian, MD, WashtenawRiad Al Natour, MD, WashtenawAmbreen Allana, MD, WashtenawDaniel Anderson, DO, WashtenawJames Applegate, MD, KentAlex Argyelan, MD, WashtenawRyan Aronberg, MD, WashtenawSindhu Avula, MD, WashtenawBathmapriya Balakrishnan, MD, WashtenawPamela Baron, MD, KalamazooFarwa Batool, MD, WashtenawHassan Baydoun, MD, WashtenawDawn Becker, MD, WashtenawLorenzo Berlanga, MD, MidlandSeth Bernard, DO, GeneseeLindsey Bewley, DO, InghamPriyanka Bikkina, MD, WashtenawKatrina Blanch, MD, WashtenawDavid Blumenthal, MD, WashtenawBobby Boyanton, Jr, MD, Oakland Joshua Bradish, MD, KalamazooMichael Brozik, MD, WashtenawEve Brusie, DO, InghamJade Burch, MD, WashtenawKatherine Caretti, MD, WayneJennifer Castillo, MD, WashtenawRichard Cattaneo, MD, WashtenawMyungwon Chang, MD, WashtenawTimothy Chaprnka, DO, KentAlexandra Chis, MD, WashtenawTendai Chiware, MD, WashtenawDennis Choi, MD, WashtenawRaymond Cole, DO, WashtenawCharles Croteau, DO, KalamazooBenjamin Davies, MD, WashtenawTroy Davis, DO, HillsdaleKatherine Davis, MD, WashtenawKathleen DeHorn, MD, KentJeffrey Devries, MD, MPH OaklandCarter, DOcking, MD, WashtenawRajiv, DOddamani, MD, WashtenawJohn, DOnkersloot, MD, WashtenawMark Drogowski, MD, NorthernTaiwo Durowade, MD, WashtenawMoushumi Dutta, MD, WashtenawAriadne Ebel, MD, Washtenaw

Andrew Egger, MD, WashtenawShafaq Ejaz, MD, WashtenawDaniel Felling, MD, WashtenawGarrett Fisher, DO, InghamJamie Frost, DO, KentDanielle Gagnon, MD, WashtenawMala Gaind, MD, OaklandBrian Gallagher, MD, WashtenawQuyen Garcia, DO, InghamSohaib Gilani, MD, WashtenawAnshum Goel, MD, WashtenawSirisha Gokaraju, MD, WashtenawAndrew Gordon, DO, InghamElizabeth Gordon Spratt, MD, WashtenawKaren Guy, MD, WashtenawKevin Hannawa, MD, KalamazooAbdul Hasan, MD, OaklandAndrew Heaford, MD, KentJames Hecksel, DO, KentJennifer Hines, MD, WashtenawWhitney Hitchcock, MD, WashtenawStaci Hopkins, MD, OaklandJeffrey Howe, MD, WashtenawAshley Huff, MD, SaginawMichael Huvard, MD, WashtenawTonya Hyde, MD, WashtenawEdwin Itenberg, DO, OaklandMiles Jackson, MD, WashtenawJames Jeltema, DO, InghamNoah Jentzen, MD, WashtenawDaniel Jeung, MD, WashtenawTheodore John, MD, WashtenawShepard Johnson, MD, WashtenawZhyldyz Kabaeva, MD, WashtenawJacqueline Kabongo, MD, WashtenawPalak Kachhadia, MD, WashtenawCrystal Kavanagh, MD, WashtenawJeffrey Kedrowski, DO, InghamMelissa Kennedy, MD, OaklandSharif Kershah, MD, WayneAyesha Khan, MD, WashtenawRhami Khorfan, MD, WashtenawThomas Kim, MD, KalamazooJared Knol, MD, KentMariko Kohlmeier, MD, WashtenawCarranda Koop, MD, WashtenawEdward Kreimier, MD, WashtenawElisa Kucia, MD, WashtenawTony Kuzhippala, MD, WashtenawMichael LaFata, MD, WashtenawKeith Langlois, MD, WashtenawEric Lerche, DO, Grand TraverseMelani Lighter, MD, WashtenawAmber Liles, MD, WashtenawNathan Liles, MD, WashtenawRobert Lin, MD, WashtenawTalya Lorenz, MD, WashtenawLaura Lozier, MD, WashtenawCatriona Macardle, MD, WashtenawJarrod MacFarlane, DO, KentMahender Macha, MD, FACS JacksonEmily Maris, MD, WashtenawRuby Marr, MD, WashtenawMarko Martinovski, MD, WashtenawAmi Mavani, MD, OaklandCarmen McIntyre, MD, WayneJackie Michaels, DO, InghamEric Mitchell, MD, KentHrishabh Modi, MD, WashtenawAndrew Moriarity, MD, KentKathryn Moseley, MD, MPH WayneSara Muszynski, MD, WashtenawMohammed Nabhan, MD, WashtenawRama Nagireddi, MD, WashtenawAndrew Nash, MD, KentAbby Navratil, MD, WashtenawKevin Nguyen, DO, InghamVictoria Nichols, DO, Washtenaw

Stephanie Norris, DO, WashtenawJohnna Nynas, MD, WashtenawNancy Omorodion, MD, WashtenawJennifer O’Neill, DO, WashtenawJill Onesti, MD, KentAnnelie Ott, MD, WashtenawTolutope Oyasiji, MD, GeneseeStephanie Pannell, MD, WashtenawCaitlin Parker, MD, WashtenawAnkit Patel, MD, WashtenawDevin Patel, MD, WashtenawSylvester Paulasir, MD, WashtenawLuke Pesonen, MD, WashtenawKatherine Petrin, MD, WashtenawSteven Petrovas, MD, KentNaudia Pickens, MD, Ingham* *chose county she lives in, not works inRobert Pinney, MD, LapeerCara Poland, MD, KentAdam Powell, DO, InghamEdward Qiao, MD, WashtenawJoanna Quigley, MD, WashtenawHera Qureshi, DO, InghamRoger Ramcharan, MD, WashtenawPatrick Rao, MD, KentBalaguru Ravi, MD, WashtenawSeth Raymond, DO, KalamazooKatherine Riddle, MD, WashtenawRobert Riley, MD, KentLeslie Rocher, MD, OaklandRonald Romero, MD, WashtenawBenjamin Roose, MD, WashtenawAndrew Rosko, MD, WashtenawHyacinth Ruiter, MD, KalamazooWendy Sadoff, MD, OaklandAdam Saugen, DO, InghamChad Savage, MD, LivingstonJoseph Seymour, MD, WashtenawSufiya Shaik, MD, WashtenawMichael Sharghi, MD, KalamazooMariko Shelton, MD, WashtenawOlabisi Sheppard, MD, WashtenawFarhaj Siddiqui, MD, SaginawTaeyong Sim, MD, WashtenawManvinder Singh, MD, OaklandStephanie Spann, MD, WashtenawKristen Spoor, MD, WashtenawZbigniew Srodulski, MD, KalamazooAndrea Starostanko, MD, WashtenawMichael Stein, DO, InghamMaria Sturla, MD, WashtenawMelissa Sundermann, DO, WashtenawKarine Tawagi, MD, WashtenawChristopher Therasse, MD, KalamazooChristopher Thuruthumaly, MD, WashtenawMark Tierney, MD, PhD KentCharles Todoroff, MD, MedicalMuhammad Usman, MD, WashtenawDavid Van Winkle, MD, MuskegonAmy Vandenberg, MD, WashtenawAela Vely, MD, WashtenawStuart Vollmer, MD, KentAlan Vorst, MD, WashtenawAbdullah Wafa, MD, WashtenawJeffrey Walker, MD, WashtenawR. Corey Waller, MD, KentJenny Wang, DO, KalamazooBradley Warlick, MD, Marquette/AlgerCory Wernimont, MD, WashtenawJoel Wilkie, MD, WashtenawDavid Wilson, MD, MuskegonMala Young, MD, WashtenawDima Youssef, MD, Washtenaw

10-5-2015 to 11-20-2015Ibrahim Abou Daya, MD, SaginawJoseph Adel, MD, SaginawAdebayo Akindele, MD, GeneseePriya Alagappan, MD, Marquette/AlgerWajdi Al-Shweiat, MD, GeneseeCindy Anderson, MD, Marquette/AlgerRichard Armstrong, MD, FACS, LuceTadesse Beyene, MD, OaklandShelley Binkley, MD, WayneEric Bryant, MD, CalhounBret Burlingame, DO, OaklandSusan Caldwell, MD, ClintonRaza Cheema, MD, GeneseeForrest Cote, DO, InghamAaron Cutlip, MD, Marquette/AlgerFanny DelaCruz, MD, OaklandJeffrey Desmond, MD, WashtenawVeronica Dula, MD, HillsdaleRita Eckenrode, MD, WashtenawJoshua Ehrlich, MD, WashtenawLuke Elliott, MD, WayneSara Elsayed, MD, GeneseeStephanie Fleming, MD, InghamJason Frost, DO, KentKathleen Fulcher, DO, Marquette/AlgerJulie Gleesing, DO, MacombSandeep Grewal, MD, GeneseeSean Growney, DO, OttawaAkhil Gulati, MD, OaklandMagdalene Gyuricska, MD, GeneseeRyan Hadley, MD, KentSamantha Haken, MD, Marquette/AlgerEvan Halchishick, DO, OaklandMaria Han, MD, WashtenawAli Harb, MD, WayneRandy Janczyk, MD, OaklandMilena Jani, MD, KentHugh Kerr, MD, OaklandSteven Kronick, MD, WashtenawGeoffrey Lam, MD, KentBrian LeCleir, MD, KentRandall Leja, DO, KentAdam Lenger, MD, KentMarie Lozon, MD, WashtenawTyson Luoma, DO, Marquette/AlgerMaggie Lyles, DO, BranchJohn Mackovjak, MD, Isabella/ClareLisa MacLean, MD, MonroeDaniel McClung, MD, WashtenawMaureen Mead, MD, Alpena/Alcona/ Presque IsleRicky Meyer, MD, SaginawEric Migoya, DO, OaklandJohn Mills, MD, WashtenawGeetha Mohan, MD, Alpena/Alcona/ Presque IsleSergio Montoya, MD, JacksonClaudia Nadernejad, MD, KentSudha Nallani, MD, SaginawJinny Oh, DO, InghamMolly O’Kane, DO, KentMark Pankonin, MD, SaginawCarmen Paredes Saenz, MD, GeneseeSana Patel, MD, InghamAmish Patel, DO, OaklandPayal Patel, DO, WashtenawRosalie Pilbeam, DO, KentJeannette Prentice, MD, KentMichael Prysak, MD, WayneNavneet Randhawa, MD, GeneseeSandeep Randhawa, MD, OaklandCarrie Ricci, MD, Alpena/Alcona/Presque IsleJennifer Rimmke, MD, MacombLiana Rinzler, MD, KentEmma Rodgers-Biebuyck, DO, EmmetJulie Rogers, MD, KentAliye Runyan, MD, Wayne


Would You Like To Place A Classified Ad?The rate for classified advertising in Michigan Medicine, including both print and online versions, is$1.60 per word, with a minimum of $65.00. All ads must be prepaid. Text for classified advertisements andadvertising fees should be received no later than the first of the month proceeding the month of publication.

All submitted ads must be typed. No handwritten or dictated ads will be accepted.

To place an ad call Carl Mischka at 888-666-1491 or email [email protected].

T H E M A R K E T P L A C E

Hurley Medical Center/Michigan State University

COMBINED INTERNAL MEDICINE/ PEDIATRICS OPPORTUNITY

As part of the Michigan State University College of Human Medicine Flint, MI Campus, Hurley Medical Center is seeking an energetic and dynamic individual to lead and/or be faculty in our Combined Internal Medicine/Pediatrics clinic. The candidate( s) must be board certified in internal medicine and pediatrics and be willing to teach medical students and residents and participate as an active faculty member in the Combined Internal Medicine/Pediatrics residency training program. Candidates must have strong interpersonal, teamwork, leadership, com-munication, tech savvy skills and a willingness to work with an urban population. The Combined Internal Medicine/Pediatrics clinic is located in a Federally Qualified Health Center. A faculty appointment will be available with the Michigan State University College of Human Medicine at a rank commensurate with experience.

Send CV to: James Buterakos, Academic Officer and DIO , Hurley Medi-cal Center, One Hurley Plaza, Flint MI 48503, Email: [email protected] or fax: 810.760.9956.

Hurley Medical Center is an equal opportunity employer

Tri-State OccupationalMedicine, Inc.

PHYSICIANS WANTED - DETROIT AREA

Tri-State Occupational Medicine, Inc. (TSOM) is looking for physicians to join their group to perform disability evaluations in Detroit. Part-time opportu-nities available. No treatment is recommended or performed. No on-call or weekends. Physicians working for us have various backgrounds and training including General Practice, IM, FP, Pedi-atrics, Pain Management, Surgery, and Cardiology. Training and all administrative needs, including scheduling, transcription, assisting and billing are provided. Interested physicians must have a current MI medical license and be in good standing. TSOM has an excellent reputation for providing Consulta-tive Evaluations for numerous state disability offices.

Contact: Susan Gladys / [email protected] phone 866-929-8766 / fax 866-712-5202

The theme for the May-June 2016 issue of Michigan Medicine will be:

The advertising deadline for the May-June 2016 issue is April 8th.Reserve your space today!


Family Practicesn Allen Park: Retired Orthopedic Surgeon offering turn key operation. Full

PT Lab, receive patient files, lots of potential for a very low price asking

$50,000.

n East Pointe Primary Care: Near I94 and Kelly Road. 3 Exam rooms, 2

year old practice. Asking $60,000 includes equipment/goodwill and

transition. Real estate available.

n Farmington Hills: Long established Internal Medicine Practice, 10 Mile/

Middlebelt area. Free standing building, 5 exam rooms, lab, x-ray. Very

close to Botsford, St. Mary’s, and Providence Novi. Asking $175,000 for

practice.

n Garden City Internal Med Practice: Long established, majority of

patients Medicare. Fully equipped, grossing in excess of $200,000

annually. Asking $70,000.

n Mexican Town Detroit: 20 year old Primary Care Clinic. Staff is fluent in

multiple languages. Seller financing available, priced to sell, work as

you pay terms. Never in 25 years have I had the opportunity to offer

more flexible terms. Price reduced to $589,000 for everything including

real estate.

n Lincoln Park: Walk-in clinic. Very visible, long established, seeing

approximately 40 patients daily. Approx. gross income $800,000. Asking

$250,000 for practice and $350,000 for real estate.

n Podiatry Practices Detroit: 2 locations, very successful, grossing in

excess of $600,000 annually. Fully equipped. Asking $300,000 for both

locations. Real estate available.

n Westside Detroit, Primary Care Practice: Established 2005, grossing in

excess of $500,000 annually. Fully equipped. Asking $200,000 owner

wants to retire.

Medical Buildings For Sale or Leasen Pontiac: Large professional medical building. Three story, suites 500-

5,000 sq. ft. Across from hospital, acres of parking. VERY REASONABLE

rates/terms or buy building for $250,000.

n West Side Detroit: 8,000 square feet, multi suites, fully leased. $60,000

positive cash flow excellent. Brick, single story asking $500,000 or lease

for $1.00 square foot plus utilities.

For more details contact ourpractice specialist at Union Realty:

Joe Zrenchik, Broker248-240-2141 (cell)

[email protected] (office)

Thinking about retirement, relocation or expansionof your medical practice?

We have buyers and sellers for primary care,internal medicine and cardiology practices.


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• Full Billing Services• Credentialing Services• Business Planning• Electronic Health Records

• Accounts Receivable Recovery Services• New Practice Start-Up• Flexible Practice Management Software Options

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A successful practice requires more than talented individuals and a desire to heal. Let Kerr Russell provide the legal insight needed to manage and grow your business.

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Patients trust you.

For more information, please contact: Daniel J. Schulte [email protected] Patrick J. Haddad [email protected] 500 Woodward Avenue, Suite 2500 Detroit, Michigan 48226 T: 313.961.0200 / F: 313.961.0388

ENTITY FORMATION • BUSINESS MATTERS • EMPLOYMENT CONTRACTS • PURCHASE / SALE OF OWNERSHIP

INTERESTS • MALPRACTICE AND ALL OTHER COMMERCIAL LITIGATION • APPEALS • MEDICAL STAFF PRIVILEGE DISPUTES HOSPITAL RELATIONS MATTERS • HEALTHCARE FRAUD DEFENSE • LICENSING AND OTHER REGULATORY MATTERS

ENTITY FORMATION • BUSINESS MATTERS • EMPLOYMENT CONTRACTS • PURCHASE / SALE OF OWNERSHIP

INTERESTS • MALPRACTICE AND ALL OTHER COMMERCIAL LITIGATION • APPEALS • MEDICAL STAFF PRIVILEGE DISPUTES HOSPITAL RELATIONS MATTERS • HEALTHCARE FRAUD DEFENSE • LICENSING AND OTHER REGULATORY MATTERS


Five Tax Planning Ideas BY JIM NIEDZINSKI, AIF®

Consider converting a Traditional IRA to a Roth IRA. A Roth IRA is powerful because it grows tax free. Anyone can convert an IRA to a Roth, but not everyone should because of the taxes due on the conversion.

Give close consideration to a Roth conversion if:• You experience a low income year –

perhaps you have recently retired or are in between jobs

• You have significant losses that can offset taxable income

• Your IRA contains after-tax contributions

• You are subject to AMT (which has a marginal rate that tops out at 28%)

• You do not plan to use the IRA dollars and want to build a tax-free nest egg for future generations

Plan for the Alternative Minimum Tax (AMT). The AMT is an “alternative” income tax de-signed to prevent wealthier tax payers from enjoying too many tax breaks and loopholes under the standard tax system.

Certain factors raise the risk of falling prey to the AMT, such as: • Living in high income tax states such as

New York or California• Owning a large home or multiple homes

with sizeable property taxes• Claiming a large amount of miscellaneous

deductions• Earning more than $158,900 – and

especially earning over $492,500

Consult with your accountant if you are at risk of the AMT. It can be confusing to plan for the AMT because the ways to save tax when you are subject to the AMT are actions that would normally increase your tax bill – such as acceler-ating ordinary income into the current year and deferring deductions into the following year.

Provide support to your children or grandchildren tax efficiently. Consider tax-wise ways to support your family and pass your wealth to loved ones.

Contribute to a 529 college saving plan. Some states, such as Michigan, provide an income tax deduction for contributions made to a state-sponsored plan. Furthermore, 529 sav-ings plans grow tax free when withdrawn for qualified education expenses.

Gift appreciated securities to family members in a lower tax bracket. Long-term capital gain rates range from a low of 0% (yes, zero!) to a high of 23.8%. You can gift securities with unreal-ized gains in lieu of cash to children who earn modest incomes. They can sell the security and pay a lower capital gain tax or potentially no tax at all. However, be careful to steer clear of the “kiddie tax” where dependent children under 19 and full-time students under 24 with un-earned income over $2,100 (in 2015) are taxed at the parent’s tax rate instead of the child’s rate.

Help children establish a Roth IRA. They can make a contribution up to the amount they earn or $5,500 (2015), whichever is less. Roth IRAs grow free of tax, including the “kiddie tax” trap described above.

Employ children. If you own a practice you might consider hiring your child to work at your com-pany for a summer job or during winter break. This enables you to divert income to them at their lower income tax rate vs. you earning the money, paying tax at your much higher margin-al rate, and giving it to them as allowance.

For high income earners, taxes may be the largest expense paid each year. Tax planning strategies are an important

component of a sound financial plan, especially for the affluent. Introducing effective tax planning strategies into your plan can save money, creating the opportunity for greater investing or spending. Here are five ideas to consider:

Maximize the tax savings of your charitable donations. While gifts of cash can provide you with a valuable tax deduction, there are ways to save even more.

Gift securities with unrealized long-term capital gains to avoid paying the capital gain tax that you would otherwise eventually owe.

Gift cash directly from your IRA. On Friday, De-cember 18, 2015, President Obama signed a tax bill into law that extended more than 50 expired provisions of the tax code. One of those provisions, the “Qualified Charitable Distribution” (QCD), has been made perma-nent by the law. A QCD allows those over age 70½ to gift up to $100,000 per year from their IRA directly to a charity and have it count as their required minimum distribution without increasing their adjusted gross income.

Consider contributing to a Donor Advised Fund. A Donor Advised Fund (DAF) can be opened at many community foundations or at invest-ment custodians such as Schwab Charitable or Fidelity Charitable. You can contribute cash or securities to your DAF and receive the full allowable tax deduction. You may then request distributions be made to the charity or chari-ties of your choice immediately or at any time in the future.

Jim Niedzinski, AIF® is an advisor at WealthCare Advisors, LLC – an MSMS joint venture.

http://www.schwabcharitable.org/public/charitable/home

http://www.fidelitycharitable.org/index.shtml

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Cash Flow Optimized is a service mark of The PNC Financial Services Group, Inc. (“PNC”). Banking and lending products and services, bank deposit products, and treasury management services, including, but not limited to, services for healthcare providers and payers, are provided by PNC Bank, National Association, a wholly owned subsidiary of PNC and Member FDIC. Lending and leasing products and services, including card services and merchant services, as well as certain other banking products and services, may require credit approval. All loans and lines of credit are subject to credit approval and require automatic payment deduction from a PNC Bank business checking account. Origination and annual fees may apply. ©2015 The PNC Financial Services Group, Inc. All rights reserved. PNC Bank, National Association. Member FDIC

KNOW YOU HAVE A DEDICATED BANKER WHO UNDERSTANDS YOUR INDUSTRY AND YOUR NEEDS. As a healthcare professional, you want to spend more time helping patients and less time worrying about your finances. With dedicated Healthcare Business Bankers, PNC provides tools and guidance to help you get more from your practice. The PNC Advantage for Healthcare Professionals helps physicians handle a range of cash flow challenges including insurance payments, equipment purchases, and managing receivables and payables. In such a fast-moving business, PNC understands how important it is to have a trusted advisor with deep industry knowledge, dedication and a lasting commitment.

Call a Healthcare Business Banker at 877-566-1355 or go to pnc.com/hcprofessionals

helps you make the most of your practice’s revenue cycle.

ENSURE ACCESS TO CREDIT | ACCELERATE RECEIVABLES | IMPROVE PAYMENT PRACTICES | MONITOR & PROJECT CASH | PURSUE FINANCIAL WELL-BEING

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michigan medicine, volume 115, no. 2

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